Many studies have examined gender-related differences in symptoms of acute myocardial infarction (AMI). However, findings have been inconsistent, largely because of different study populations and different methods of symptom assessment and data analysis. This study was based on 568 women and 1,710 men 25 to 74 years old hospitalized with a first-ever AMI from January 2001 through December 2006 recruited from a population-based AMI registry. Occurrence of 13 AMI symptoms was recorded using standardized patient interview. After controlling for age, migration status, body mass index, smoking, some co-morbidities including diabetes, and type and location of AMI through logistic regression modeling, women were significantly more likely to complain of pain in the left shoulder/arm/hand (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.10 to 1.69), pain in the throat/jaw (OR 1.78, 95% CI 1.43 to 2.21), pain in the upper abdomen (OR 1.39, 95% CI 1.02 to 1.91), pain between the shoulder blades (OR 2.22, 95% CI 1.78 to 2.77), vomiting (OR 2.23, 95% CI 1.67 to 2.97), nausea (OR 1.94, 95% CI 1.56 to 2.39), dyspnea (OR 1.45, 95% CI 1.17 to 1.78), fear of death (OR 2.17, 95% CI 1.73 to 2.72), and dizziness (OR 1.49, 95% CI 1.16 to 1.91) than men. Furthermore, women were more likely to report >4 symptoms (OR 2.14, 95% CI 1.72 to 2.66). No significant gender differences were found in chest pain, feelings of pressure or tightness, diaphoresis, pain in the right shoulder/arm/hand, and syncope. In conclusion, women and men did not differ regarding the chief AMI symptoms of chest pain or feelings of tightness or pressure and diaphoresis. However, women were more likely to have additional symptoms.
The objective of this study was to investigate gender differences in self-reported acute myocardial infarction (AMI) symptoms in a well-defined, population-based sample of patients with a first-ever AMI taking into account several confounding variables.
Methods
As part of the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) project, a population-based Augsburg Coronary Event Registry was implemented in 1984. After termination of MONICA in 1995, the registry became part of the framework of Cooperative Health Research in the Region of Augsburg (KORA). Since 1984, all cases of coronary deaths and nonfatal AMI of the 25- to 74-year-old study population in the city of Augsburg and 2 adjacent counties (about 600,000 inhabitants) have been continuously registered. Data sources for hospitalized patients include 8 hospitals within the study region and 2 hospitals in adjacent areas. Approximately 80% of all AMI cases of the study region are treated in the study region’s major hospital, Klinikum Augsburg, a tertiary care center offering invasive and interventional cardiovascular procedures and heart surgery facilities. Methods of case finding, diagnostic classification of events, and data quality control have been described elsewhere. Since January 1, 2001, all patients with AMI diagnosed according to criteria of the European Society of Cardiology and American College of Cardiology have been included.
In the present analysis, all registered patients from January 1, 2001 through December 31, 2006 who survived >24 hours with an incident AMI were included. Of 3,120 men and women with an incident AMI during the study period, subjects who could not be interviewed (n = 711) or whose data on any of the covariables were incomplete (n = 131) were excluded. Reasons for missing interviews were death (n = 162), patient declined an interview (n = 210), insufficient German-language skills (n = 60), early discharge (n = 38), delayed case identification (n = 125), or poor health status (e.g., impaired consciousness or orientation, n = 116). Therefore, the present analyses included 1,710 men and 568 women 25 to 74 years of age with an incident AMI.
Patients were interviewed using a standardized questionnaire during their hospital stay after transfer from the intensive care unit. Interviews were performed by trained study nurses and included demographic data, data on cardiovascular risk factors, medical history, co-morbidities including diabetes, and symptoms associated with the AMI event. The initial question on AMI symptoms was “Did you have pain in the chest or a feeling of pressure or tightness?” Patients were then asked if other symptoms and complaints had occurred. If they agreed, they were queried on the occurrence of 12 additional symptoms. The 12 symptoms were pain in the left shoulder, arm, or hand, pain in the right shoulder arm or hand, pain between the shoulder blades, pain in the upper abdomen, pain in the throat or jaw, nausea, vomiting, dizziness, syncope, dyspnea, diaphoresis, and fear of death.
Further data on co-morbidities, electrocardiogram, and in-hospital course were determined by chart review. If information on co-morbidities from patient reports and medical charts differed, the chart information was used.
Continuous data were expressed as means and categorical variables as percentages. Chi-square test was used to test differences in frequencies. The t test was used to test gender differences in continuous variables. Multiple logistic regression models were used to examine the relation between gender and occurrence of each of the 13 AMI symptoms. To adjust for potential confounders, several covariables were included in the models. Significance at the 15% level in univariate analysis of ≥6 symptoms was used as the criterion for entry in the multivariable model. The models computed for each of the 13 AMI symptoms included gender, age (<55, 55 to 64, >64 years), migration status (nationality not German or nationality of mother or father not German, yes/no), body mass index (BMI; <25, 25 to <30, 30 to <35, ≥35 kg/m 2 ), smoking (current smoker, former smoker, never smoked), history of hypertension (yes/no), angina pectoris (yes/no), hyperlipidemia (yes/no), peripheral arterial occlusive disease (yes/no), diabetes (yes/no), sleep disturbance in the previous 4 weeks (yes/no), AMI type (ST-segment elevation MI, non–ST-segment elevation MI, bundle branch block), and AMI location (anterior, posterior, undetermined).
Results
Median time between hospital admission and patient interview was 6 days (25% to 75% quartiles 4 to 9). Sample characteristics of men and women are presented in Table 1 . Frequencies of reported AMI symptoms and differences between men and women are presented in Table 2 . Table 3 lists results of multivariable logistic regression analysis indicating significant gender effects after adjustment for several covariables.
| Variable | Women (n = 568) | Men (n = 1,710) | Total (n = 2,278) |
|---|---|---|---|
| Age (years), mean ± SD ‡ | 62.9 ± 9.2 | 59.2 ± 9.6 | 60.1 ± 9.6 |
| Age (years) ‡ | |||
| <55 | 111 (19.5%) | 531 (31.1%) | 642 (28.2%) |
| 55–64 | 160 (28.2%) | 594 (34.7%) | 754 (33.1%) |
| >64 | 297 (52.3%) | 585 (34.2%) | 882 (38.7%) |
| Married ‡ | 356 (62.7%) | 1,366 (79.9%) | 1,722 (75.6%) |
| Living alone ‡ | 164 (28.9%) | 236 (13.8%) | 400 (17.6%) |
| School education ‡ | |||
| 9 years | 459 (80.8%) | 1,218 (71.2%) | 1,677 (73.6%) |
| >9 years | 106 (18.7%) | 480 (28.1%) | 586 (25.8%) |
| Other | 3 (0.5%) | 6 (0.4%) | 9 (0.4%) |
| Missing | — | 6 (0.4%) | 6 (0.3%) |
| Migrant | 49 (8.6%) | 167 (9.8%) | 216 (9.5%) |
| Body mass index (kg/m 2 ), mean ± SD ⁎ | 27.5 ± 5.4 | 27.6 ± 3.9 | 27.7 ± 4.3 |
| Body mass index (kg/m 2 ) ‡ | |||
| <25 | 185 (32.6%) | 440 (25.7%) | 625 (27.4%) |
| 25–<30 | 194 (34.2%) | 870 (50.9%) | 1,064 (46.7%) |
| 30–<35 | 130 (22.9%) | 329 (19.2%) | 459 (20.2%) |
| ≥35 | 59 (10.4%) | 71 (4.2%) | 130 (5.7%) |
| Smoker ‡ | |||
| Current | 170 (29.9%) | 668 (39.1%) | 838 (36.8%) |
| Former | 103 (18.1%) | 616 (36.0%) | 719 (31.6%) |
| Never | 295 (52.0%) | 426 (24.9%) | 721 (31.6%) |
| Hypertension ‡ | 473 (83.3%) | 1,245 (72.8%) | 1,718 (75.4%) |
| Angina pectoris | 56 (9.9%) | 174 (10.2%) | 230 (10.1%) |
| Hyperlipidemia | 400 (70.4%) | 1,158 (67.7%) | 1,558 (68.4%) |
| Peripheral arterial occlusive disease | 57 (10.0%) | 183 (10.7%) | 240 (10.5%) |
| Diabetes mellitus † | 181 (31.9%) | 431 (25.2%) | 612 (26.9%) |
| Sleep disturbance ‡ | 277 (48.8%) | 521 (30.5%) | 798 (35.0%) |
| Acute myocardial infarction type ⁎ | |||
| ST-segment elevation myocardial infarction | 220 (38.7%) | 669 (39.1%) | 889 (39.0%) |
| Non–ST-segment elevation myocardial infarction | 331 (58.3%) | 937 (54.8%) | 1,268 (55.7%) |
| Bundle branch block | 17 (3.0%) | 104 (6.1%) | 121 (5.3%) |
| Acute myocardial infarction location ⁎ | |||
| Anterior | 213 (37.5%) | 728 (42.6%) | 941 (41.3%) |
| Posterior | 279 (49.1%) | 736 (43.0%) | 1,015 (44.6%) |
| Undetermined | 76 (13.4%) | 246 (14.4%) | 322 (14.1%) |
| Women (n = 568) | Men (n = 1,710) | Total (n = 2,278) | |
|---|---|---|---|
| Number of symptoms, mean ± SD ⁎ | 5.33 ± 2.38 | 4.37 ± 2.13 | 4.61 ± 2.23 |
| Chest pain or feelings of pressure or tightness | 531 (93.5%) | 1,609 (94.2%) | 2,140 (94.0%) |
| Only chest symptoms | 15 (2.6%) | 86 (5.0%) | 101 (4.4%) |
| Pain left shoulder/arm/hand ⁎ | 344 (60.7%) | 941 (55.0%) | 1,285 (56.4%) |
| Pain right shoulder/arm/hand | 188 (33.1%) | 517 (30.2%) | 705 (31.0%) |
| Pain throat/jaw ‡ | 226 (39.9%) | 472 (27.6%) | 698 (30.7%) |
| Pain upper abdomen ⁎ | 76 (13.4%) | 173 (10.1%) | 249 (10.9%) |
| Pain between shoulder blades ‡ | 227 (40.0%) | 383 (22.4%) | 610 (26.8%) |
| Vomiting ‡ | 114 (20.1%) | 183 (10.7%) | 297 (13.0%) |
| Nausea ‡ | 269 (47.4%) | 549 (32.1%) | 818 (35.9%) |
| Dyspnea ‡ | 320 (56.3%) | 787 (46.0%) | 1,107 (48.6%) |
| Diaphoresis | 335 (59.0%) | 1,048 (61.3%) | 1,383 (60.7%) |
| Fear of death ‡ | 218 (38.4%) | 402 (23.5%) | 620 (27.2%) |
| Dizziness † | 140 (24.7%) | 332 (19.4%) | 472 (20.7%) |
| Syncope | 38 (6.7%) | 83 (4.9%) | 121 (5.3%) |
| OR (95% CI) | p Value | |
|---|---|---|
| Vomiting | 2.23 (1.67–2.97) | <0.01 |
| Pain between shoulder blades | 2.22 (1.78–2.77) | <0.01 |
| Fear of death | 2.17 (1.73–2.72) | <0.01 |
| >4 symptoms | 2.14 (1.72–2.66) | <0.01 |
| Nausea | 1.94 (1.56–2.39) | <0.01 |
| Pain in throat/jaw | 1.78 (1.43–2.21) | <0.01 |
| Syncope | 1.55 (1.00–2.39) | 0.05 |
| Dizziness | 1.49 (1.16–1.91) | <0.01 |
| Dyspnea | 1.45 (1.17–1.78) | <0.01 |
| Pain in upper abdomen | 1.39 (1.02–1.91) | 0.04 |
| Pain in left shoulder/arm/hand | 1.36 (1.10–1.69) | <0.01 |
| Pain in right shoulder/arm/hand | 1.19 (0.95–1.48) | 0.12 |
| Diaphoresis | 0.93 (0.75–1.15) | 0.49 |
| Chest pain or feelings of pressure or tightness | 0.83 (0.54–1.28) | 0.40 |
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